Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Tuesday, September 6, 2011

Decision Fatigue

We make more decisions and have more accountability than ever before. Regulatory complexity and the need for risk management has increased. We're pressured to make decisions faster and there is less tolerance for mistakes. Making all those decisions in a high stakes environment like healthcare leads to decision fatigue, that numbness you feel at the end of an overloaded day when you decided what to spend, who to hire, and what to do, hundreds of times.

I believe decision fatigue is an escalating threat to our ability to manage the events of each day and keep balance in our lives.

When I think back on my early career as a leader, in the 1980's, there was no email, no overnight shipping, and limited numbers of fax machines.

Issues were escalated by writing and mailing a letter. The time it took to compose, type, mail, and deliver a letter meant that many problems solved themselves. Since the effort to escalate was significant, many problems were never escalated.

Today, everyone can escalate everything to anyone. The barrier to communicating is nearly zero and communication is real time. There is no mail room or team of middle management filters between you and the CEO.

This creates an interesting conundrum for leaders. Should everything be answered in a very timely way with Solomon-like decisions about every issue? Should everything be ignored unless truly emergent with the hope that someone else will solve the problem? Should everything be deflected to those in middle management who would have read paper-based mail?

My goal is to never be the rate limiting step. That means that I make hundreds of decisions every day. Some are right and some are wrong, but they are the best answers given the information that I have. In the IT industry, timely action that is good enough is often more important than a delayed perfect action.

Thus at the end of every day my brain is whirring with thousands of inputs, and hundreds of decisions made. I'm not physically tired after any workday, but I can feel mentally tired from decision fatigue.

The problem with decision fatigue is the that quality of decisions can diminish as the quantity of issues increases.

There are two ways to address decision fatigue

1. Reduce the scope of your authority and hence the decisions you need to make and the risks you need to manage. I'll post a blog next week about span of authority and risk management.

2. Spread decisions over a wider group of people, reducing the volume of decisions that fall to any one person.

#2 depends upon having a great boss, who is supportive, responsive, and willing to share decision making risk with you. #2 also requires great staff whom you can empower to make decisions on their own.

Thus, I make the decisions that I am uniquely qualified to make, while pushing others up and down the organizational hierarchy so that risk is mitigated (seeking approval up the org chart) and trusted staff are given the resources and authority to solve problems on their own (delegating down the org chart).

Here's an example of how I managed decision fatigue today. Between 3pm and 4pm, I was asked to make several decisions:

1. The regional poison control center sought my input on a mushroom ingestion case. A 1 year old had taken a large bite from a mushroom growing in a backyard. Since I uniquely have mushroom toxicology knowledge, this was my decision. The mushroom was a harmless Lactarius Fragilis and I decided that the child would be fine.

2. A leak in the Longwood Medical Area chilled water supply caused a 5 degree rise in our disaster recovery data center. What should we do? I ensured that all appropriate facilities and IT people were organized to address the problem, and asked to be informed if the temperature exceeded 90F. The incident management decision making was delegated to others.

3. A researcher in one of the Harvard buildings suspected that the network had been hacked because www.ups.com was unavailable. Should I page security and networking staff to urgently investigate this on a holiday weekend? I used my Blackberry to replicate the problem and escalated it to IT security, who found the problem was unrelated to our network/DNS servers. The incident management decision making was delegated to others.

In the next few months, I'll be finishing the FY12 Operating Plan for BIDMC IS, so there will be plenty of decision making to spread among governance committees and executive management.

One other cure for decision fatigue that I recommend is a "time out". On my way home in the evening, I stop at our community garden space to sit on the small bench we've placed there, eat a few cherry tomatoes wrapped in basil, and watch the birds peck at our sunflowers. I leave my Blackberry in the car. By the time I get home, the decision fatigue of the day has passed, so when my wife and I discuss dinner choices, I'm ready to act boldy.

3 comments:

This is why I'm a big fan of Dashboarding and visualization. I don't necessarily believe that current dashboarding tools work right yet, but I believe that's the path:

Put the information in front of you, visually. Allow you to drill down to what you want quickly. Allow you to easily share that discovery. I think this will allow for clean delegation.

That means that dashboarding software will need to let report-builders mash-up any kind of data, properly normalize it and present it in a way that makes sense. That's the difficult part. We're on our way, but not there yet.

John, thanks for this great blog post. I love the comment you make about how things used to just work themselves out just by the amount of time it would take to escalate the issue. I was mentored years ago to 'beware of the tyranny of the urgent'. I was finding myself consumed by making decisions for everyone I worked with. I could barely do my own job. I realized my personality was one that wanted to help others, and to feel important, but that was getting in the way of being able to do the work I was responsible for. I was also useless to help my kids and wife make decisions when I got home.

My solution at work, when my employees would want my input/decision, was to require them to come back in 10, 15, or 30 minutes (if I had the time then) and ask me again. This let them know that my time was valuable, and that I was busy with my own decisions. Basically, unless it was an emergency I would delay my input. What normally ended up happening is the issue would just go away or be solved by the employee. This gave them more confidence in their own ability to solve problems without my input. I would then follow up and ask how they solved the issue giving my input and feedback at a time when I had the time.

I found a lot more mind freedom when I let go and let others make decisions around me.

Many decisions are related to "putting out fires" rather than working toward completing a project. Putting out fires seems to consume more and more of the workday, pushing project work further behind schedule.

Too many projects, on the other hand, are infected by the "putting out fires" mentality. That is, the overriding managerial belief is that "There is never time to do it right, but there is always time to do it over." Time, in this sense, is a shorthand for resources.